Medicare AdvantagePrior AuthMedium impact
Pemazyre (pemigatinib) (Revised)
Humana·Oncology, Hematology, Internal Medicine·Medicare Advantage
Effective date
Mar 25, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage updated its Pemazyre (pemigatinib) prior authorization policy effective March 25, 2026. The policy clarifies coverage for two indications: (1) unresectable locally advanced or metastatic cholangiocarcinoma with FGFR2 fusion/rearrangement after prior treatment, and (2) relapsed or refractory myeloid/lymphoid neoplasms with FGFR1 rearrangement. Both require prior authorization with 6-month initial and renewal approval periods. Claims will be denied if members have experienced disease progression on Pemazyre.
Action Required
By March 25, 2026: Billing and prior authorization teams must implement the updated Pemazyre prior authorization requirements in all billing systems and preauthorization workflows for Humana Medicare Advantage members. (1) For cholangiocarcinoma claims: Verify member has unresectable locally advanced or metastatic disease with documented FGFR2 fusion/rearrangement from FDA-approved test AND prior treatment history before submitting for prior auth. (2) For myeloid/lymphoid neoplasm claims: Verify documented FGFR1 rearrangement before submitting for prior auth. (3) Add exclusion check to all preauthorization templates: Do NOT approve if member has prior disease progression on Pemazyre. (4) Update authorization duration settings to 6 months for both initial and renewal approvals. (5) Educate providers that Pemazyre must be used as single agent for subsequent therapy in cholangiocarcinoma cases. (6) Update internal documentation checklist to require genetic testing evidence before preauthorization submission. Claims submitted without proper prior authorization or missing required documentation will be denied by Humana. Contact Humana's PAL (Preauthorization and Notification List) at www.humana.com/PAL for medical billing coding requirements.